This form is intended to be printed, completed and mailed through the U.S. Postal Service. Forms or replications of forms returned by e-mail will not be accepted for processing.

Board of Industrial Insurance Appeals 
PO Box 42401 Olympia, WA 98504-2401

Crime Victim NOTICE OF APPEAL

If you disagree with a decision of the Department of Labor and Industries concerning a crime victim's claim, this form can be used to file an appeal of that decision. You must file the appeal with the Board of Industrial Insurance Appeals, WITHIN 90 DAYS of the date you received the Department’s decision. The appeal can be filed with the Board personally or by mail at the above address.

Today's date:_______________:

Appeal filed by __Claimant __Beneficiary __ Guardian __Estate of

Claimant's Name _______________________________________ 

Crime Victim No: ________________

I wish to appeal the decision of the Department of Labor and Industries dated: ____________________ [copy attached]

The situation arose on (Date) _____________, at (Location) ________________________

I disagree with the Department’s decision because:

What are you asking for?

I desire to have any proceedings held in: (City) ________________

I believe the above statement to be true._________

(Signature)	Phone: (H)		(W)
Name: (Please Print)	Social Security No:
Address:	City:	State:		Zip
It is important that the Board be able to reach you concerning your appeal. If you do not have a phone, please provide the number of a friend/relative where the Board can leave a message. Also, please notify the Board if you change your address.